Weekly monitoring (1-hour visit each week) to assist with vitals, medication setup, visits to MD appointments, mediation with family, MMSE (Mini-Mental-State Exam); coordination with caregiver agency staff to ensure family and caregiver are aligned with Care Plan; crisis and ongoing clinical oversight and recommendations to prevent hospitalization

Clinical recommendations/oversight by RN, social worker and/or a healthcare advocate

Coordination/communication with physicians, family members and specialists

Accompaniment to and Advocacy at MD appointments to assist the client in better understanding his/her medical needs and relay information to the client’s family

Referrals to services for client’s ongoing needs (skilled home care, non-skilled home care, durable medical equipment, counseling, MD, rehab, dietitian, housing, legal, financial services)

Documentation of health history/medication list for MDs

Nursing care (wound care; gastrostomy tube feedings; head-to-toe assessment; notifications to MDs regarding significant findings and to begin intervention; last-minute home visits if client isn’t feeling well)

Coordination of all home care services

Counseling

Evaluation for and arrangement of durable medical equipment

Liaison to long-distance families

Provision of community resources and setup of Emergency Response System (e.g. Lifeline)

Assistance with personal errands